Med Surg 2 Respiratory Notes PDF

Concepts of Care for Patients with Noninfectious Upper Respiratory Problems Priority Concept: Gas Exchange Gas exchange is oxygen transport to the cells and carbon dioxide transport away from cells. Exemplar for this chapter is Obstructive Sleep Apnea and interrelated concept is tissue integrity Pr...

Concepts of Care for Patients with Noninfectious Upper Respiratory Problems Priority Concept: Gas Exchange Gas exchange is oxygen transport to the cells and carbon dioxide transport away from cells. Exemplar for this chapter is Obstructive Sleep Apnea and interrelated concept is tissue integrity Problems that obstruct ventilation and diffusion makes the nursing priority to promote gas exchange by ensuring a continuous patent airway for the patient experiencing disorders of the upper respiratory tract. Pathophysiology Review Upper airway obstruction- interruption of airflow through nose, mouth, pharynx, or larynx This obstruction can be caused by tongue edema, tongue occlusion, laryngeal edema, pharyngeal abscess, head/neck cancer, thick secretions, stroke/cerebral edema, trauma/burns, and foreign body aspiration. Nursing safety priority for those who are at risk for mucoid impaction is oral hygiene. The nurse should assess the patient’s need for oral care daily through reviewing if there are any thickly crusted secretions and assisting the personnel who provide the oral care. Assessment: Recognizing cues Partial obstruction includes symptoms such as diaphoresis, tachycardia, anxiety, and elevated blood pressure. Persistent symptoms must be reviewed via chest/neck x-rays. Laryngoscopic examination, and CT. Nurses should also assess for hypoxia, hypercarbia, restlessness, increasing anxiety, sternal retractions, a “seesawing” chest motion, abdominal movements, or a feeling of impending doom from air hunger. To monitor for adequate gas exchange, the nurse should assess the patient’s O2 stat and signs for stridor, cyanosis, and changes in level of consciousness. Interventions: Take Action Before taking action, the nurse should assess what is primarily causing the obstruction. If the patient is experiencing excessive secretions, the nurse should extend the patient’s head and neck and insert a nasal/oral airway while suctioning to remove the obstructing secretions. If unsuccessful, abdominal thrusts should be administered ONLY WHEN OBSTRUCTION IS PRESENT and the patient has a PALPABLE PULSE. Chest compressions are started instead since the unconscious adult is more susceptible to heart issues. An Endotracheal intubation is when a tube is inserted into the trachea via the nose/mouth in order to assist in airflow into and out from the lungs. A tracheotomy is typically used in the emergency room setting as it can establish an airway in less than 2 minutes and serves the purpose of preventing laryngeal injury and loss of tissue integrity but the endotracheal tube. Deep Vein Thrombosis The most common type of thrombophlebitis: thrombus (blood clot due to endothelial injury, venous stasis, or hypercoagulability) that is associated with inflammation. Presents as a greater risk for a pulmonary embolism. Lecture: focus on DVTs in the legs due to gravity - site is red, warm to touch, significant pain that is continuous, and swelling and inflammation will be below the blockage site Etiology Virchow Triad: the theory that endothelial injury (damage to the walls of the blood cells) , stasis (alterations in blood flow), and hypercoagulability (a state where blood is most likely to clot) contribute to the development of blood clots Complications of immobility due to prolonged bed rest where phlebitis (vein inflammation) can be associated with IV therapy can expose these post op patients to developing a blood clot. Prevention: ambulation, antithrombotic device, compression stockings - TED or SCDs Will not use mechanical stimulation because it can move clot Risks Padua Prediction Scale: VTE Risk high > 4 points History, recent illnesses, all hospitalized adults are at risk of DVT Diagnosing Risk factors Presentation Homan’s Sign: medical test where patient is forced to dorsiflex their foot while knee is extended to observe for any pain located in the calf D-Dimer: protein released from clots as they dissolve and break up; 500 ng/ml is suspicious for DVT Imaging: Ultrasound/CT/MRI Patient Safety Goals Drug Therapy: anticoagulants are the drug of choice for a DVT/prevention of DVT To reduce the likelihood of patient harm associated with anticoagulants: 1) Use approved protocols for initiation and maintenance of anticoag therapy 2) Use approved protocols for reversal of this therapy 3) Use established protocols for perioperative patients on anticoags 4) Establish ongoing lab tests to monitor and adjust therapy 5) Consistently address anticoag safety practices 6) Provide patient education - Adherence to medication dose and schedule - Importance of follow up appointments - Nutritional support including foods to avoid - Information about drug reactions or interactions (bleeding and bruising) 7) Using only unit-dose products and prefilled syringes/premixed infusion bags 8) Using programmable pumps when administering heparin IV and continuous in order to provide consistent and accurate dosing Nursing Safety Priority: If aPTT is greater than 70 seconds - notify provider. If bleeding occurs, stop the anticoagulant immediately and call the health care provider or Rapid Response Team Possible: Heparin-induced thrombocytopenia = platelet count > decreased gas exchange >> increased blood carbon dioxide levels >> decreased PH Because sleep is disrupted, the patient is unable to receive deep sleep needed for the best physiologic restoration. This apnea period can result in arterial blood oxygenation levels to reach less than 80%. SSX: chronic excessive daytime sleepiness, inability to concentrate, morning headache, irritability, nocturia Long term effects: increased risk for hypertension, stroke, cognitive deficits, weight gain, diabetes, and pulmonary/cardiovascular disease. All linked to premature deaths Etiology & Genetic Risk Most common cause of obstructive sleep apnea is UPPER AIRWAY OBSTRUCTION BY THE SOFT PALATE OR TONGUE. Contributing factors include obesity, large uvula, short neck, smoking, enlarged tonsils or adenoids, and oropharyngeal edema. Muscles of the airway relax Decreased circulation and oxygenation Assessment: Recognize Cues Patients are often unaware of having sleep apnea and usually suspected when an adult has persistent daytime sleepiness or reports “waking up tired.” Nurse should ask if a patient is experiencing any sensations of daytime sleepiness such as falling asleep while performing tasks, being awakened by their own snoring, or if family members have noticed any heavy snoring. Apneic/Hypopnea Episode Cessation of breathing during sleep more than 10 seconds an hour 5 times an hour Hypoxemia = less than 92% Common pattern includes: breaths that become further apart, periods of no breathing, chest and abdominal movements that lead to gasping and snorting, partial awakening, nightmares Nursing Considerations: Ask if they have tried to induce deeper sleep with over-the-counter sleep aids, increase alcohol consumption, awakened with heartburn - because OSA patients tend to develop GERD Physical Assessment Nurse should examine patients height and weight - overweight is a common indication of cause, examine if patient has a retracted lower jaw, smaller chin, shorter neck, shape of pharynx, size and shape of uvula, and tongue thickness and position, if adenoids/pillars/soft palate are swollen or enlarged. Assess patients blood pressure, heart rate and rhythm as chronic OSA can be associated with cardiovascular changes. Psychosocial Assessment Since irritability, depression, and personality changes are common in adults with OSA, nurses should ask patients about problems with recall, concentration, perceived energy level, and the ability to stay on task when working or studying. Impaired gas exchange >> significant cerebral hypoxia >> memory loss/dementia Diagnostic Assessment 1) Questionnaire: STOP-BANG, Epworth Sleepiness Scale Pittsburgh Sleep 2) At home sleep study - patient sleeps in his or her own bed with monitoring respiratory rate, heart rate, chest movement, eye movements, muscle activity 3) Polysomnography - direct observation of patient’s sleep wearing EEG Apnea-Hypopnea Index Severe: >30/hr Moderate: 15-30 Mild: 5-14 The primary collaborative problem for the patient with moderate to severe OSA is persistent gas exchange and hypoxia due to abnormal sleep patterns. The patient is expected to achieve a sleep pattern consistent with adequate gas exchange and longer-duration restorative sleep. Nonsurgical Management Focus: to reduce the obstruction and improve both depth and duration of restorative sleep patterns. IMPROVE GAS EXCHANGE! Stop taking any drugs that can affect their sleep, alcohol; instruct patient to sleep on their side CPAP - continuous positive airway pressure; relatively tight fit to form a seal over the nose and mouth; mask should be properly fitted to ensure comfort and proper therapeutic effect - smaller masks can help maintain tissue integrity. The equipment is fairly expensive. Adherence: minimum of 4 hours of sleep, 5-7 nights per week, continuous adherence for 3 months The reason why people do not adhere to treatment is do to the comfortability of the mask Surgical management Implanted stimulators: almost like a pacemaker but for breathing Uvulopalatopharyngoplasty: remove the uvula and remodel the oropharyngeal area modUPPP: less tissue taken out but same idea Tracheostomy: rare Nursing Priority VAPs Assess tolerance/compliance - clean mask daily and change tubing/filter regularly Switch masks if needed Assess sleep pattern Any pressure injuries Aspiration - if patient drools when they sleep Surgery Check airway, pain - to assess for airway swelling and bleeding Minimize infection Bleeding Discharge 2-3 days Evaluation: Evaluate Outcomes Expected outcomes for the patient should 1) Does not remain hypertensive or has hypertension that can be controlled with appropriate therapy 2) Adherent with prescribed nonsurgical interventions 3) Has fewer sleep-time apnea periods of 10 seconds or longer 4) Has improved gas exchange with greater duration of restorative sleep 5) Reports less day time sleepiness and has more energy 6) Has an uneventful recovery from surgical intervention Asthma One of the most common lower respiratory disorders that reduces gas exchange; can lead to severe lower airway obstruction and death. It is a chronic disease in which reversible acute airway obstruction occurs intermittently, reducing airflow via inflammation affecting the lumens and airway tissue sensitivity with bronchoconstriction. Hyper-response trigger that causes inflammation leading to bronchoconstriction thus resulting in impaired gas exchange Etiology and Genetic Risk Inflammation of the mucous membranes - occurs in response to allergens: cold air/dry air/microorganisms/aspirin Inflammation caused by white blood cells (WBCa) - too many eosinophils = hyperresponsive airways Too many neutrophils = increases inflammation leading to asthma attacks GERD: can trigger asthma in some adults at night as the stomach acid enters the airway and makes preexisting tissue sensitivity worse History Patient pattern: dyspnea, chest tightness, coughing, wheezing, increased mucus production SSX: Daytime symptoms of wheezing, dyspnea, coughing present more than twice weekly Waking up from night sleep with wheezing, dyspnea, coughing Reliever (rescue drug) needed more than twice weekly Activity limited or stopped by symptoms more than twice weekly Barrel chest: caused by air trapping: the diameter between the front and back of chest increases with air trapping giving the chest a rounded rather than oval shape Pulse oximetry shows hypoxemia; possible cyanosis in oral mucosa and nail beds; changes in level of cognition/consciousness and tachycardia Lab Assessment/Pulmonary Function Tests ABGs show the effectiveness of gas exchange; arterial oxygen (PaO2) may decrease during an asthma attack and the arterial carbon dioxide level (PaCO2) may decrease as the patient increases their breathing rate and depth. Allergic asthma often occurs with elevated serum eosinophil counts and IgE. Respiratory acidosis! The most important PFTs for asthma are FVC and FEV1 which are tested via spirometer. Asthma is diagnosed when these values increase by 12% or more after treatment with bronchodilators. Interventions: Take Action Status Asthmaticus: emergent condition; occurs when normal treatment of an asthma attack does not resolve the problem The purpose of asthma therapy is to control and prevent episodes, improve airflow and gas exchange, and relieve symptoms. TREATMENT WORKS BEST WHEN PATIENT IS AN ACTIVE PARTNER IN MANAGEMENT PLAN Treatment Control therapy drugs: used everyday regardless of symptoms to maintain gas exchange LABA (corticosteroid) Reliever Drugs: aka rescue drugs used to stop an attack once it has started SABA (corticosteroid) *must wash out mouth when using corticosteroids because they can cause a drop in immune system if left for too long* Patient Education Avoid potential environmental asthma triggers - smoke, fireplaces, dust mold, weather changes warm - cold Avoid drugs that trigger - aspirin, NSAIDs, beta blockers Avoid foods prepared with MSG If exercising, use inhaler 30 minutes before exercise to prevent/reduce a bronchospasm Ensure proper technique and correct sequence when using inhaler Get adequate rest and sleep Reduce stress and anxiety Wash all bedding to get rid of dust mites Seek emergency care if cyanotic, difficulty breathing/walking/talking, retractions of neck/chest/ribs, nasal flaring, failure of drugs to control worsening symptoms Chronic Obstructive Pulmonary Disease COPD is a collection of lower airway disorders that interfere with airflow and gas exchange. These disorders include emphysema and chronic bronchitis. Presentation and diagnosis: Orthopnea (trouble breathing), respiratory pattern, clubbing UGLY FINGERNAILS, anorexia, unintended weight loss - because all the energy is put into trying to breath that they forget to eat, cannot sleep flat, issues with ADLs Labs: CMP - elevated C02 and CO3, ABGs - chronic respiratory acidosis (hypoxemia hypocapnia), CBC - polycythemia = there is a ton of RBCs to carry oxygen but not enough oxygen to carry Complications: Hypoxemia/hypoxia, hypercapnia, chronic respiratory acidosis, polycythemia, cardiac dysrhythmias Treatment: SABAs and LABAs Nebulizer Treatment: can inhale normal saline and medication which will help open up the airways (88-92%) Exercise: 20 minute walk and add 5/abdominal exercises Diet: improve weight, consult with dietician - smaller meals with higher calories and protein, avoid caffeine/alcohol Patient management: Assess status and adequacy of Emphysema Emphysema is a destructive problem of lung elastic tissue that reduces its ability to recoil after stretching, leading to hyperinflation of the lung - results in reduced gas exchange and the need for an increased respiratory rate Proteases are present to destroy and eliminate particles inhaled during breathing. Smoking triggers synthesis of these enzymes to higher than normal levels which can damage the alveoli and small airways by breaking down elastin. The lack of recoil causes more air to be trapped which then presses down on the diaphragm and flattens it - overall causing the effectiveness of the muscle to weaken. The neck, chest, wall and abdomen have to compensate thus causing the patient to have “air hunger” and an uncoordinated breathing problem. Starts with a decrease in elastic recoil and alveolar detachment, then lung compliance is an issue Pulmonary emphysema = alveolar problem Chronic bronchitis = airway problem Chronic Bronchitis Chronic bronchitis is an inflammation of the bronchi and bronchioles caused by exposure to irritants, especially cigarette smoke. This irritant causes inflammation, vasodilation, mucosal edema, congestion, and bronchospasm. Bronchitis only affects the airways, not the alveoli. Chronic inflammation increases the number and size of mucus secreting glands = large amounts of thick mucus and the bronchial walls thicken = impaired airflow Starts with obstruction of the airway and excessive mucus is secreted, lack of oxygen to alveoli Etiology and Genetic Risk Cigarette smoking is the greatest risk factor for COPD in addition to asthma. COPD affects gas exchange and the oxygenation of all tissues Hypoxemia and acidosis occur because of the reduced gas exchange and respiratory infection risk increases because of the increase mucus and poor gas exchange Bacterial infections exacerbate COPD symptoms as it increases inflammation and mucus production and there is more bronchospasm Health Promotion Advise patients to quit smoking! The patient with emphysema has limited diaphragmatic movement because the diaphragm is flattened and below its usual resting state Laboratory Assessment ABGs identify abnormal gas exchange, oxygenation, ventilation, and acid-base status As COPD worsens = hypoxemia (O2 in blood decreases) and hypercapnia (CO2 increases) Pulmonary Embolism An embolism is a clot that originates from a different place and has traveled somewhere it gets lodged A DVT is a clot that forms in the leg, and when it breaks off it becomes an embolism and travels into the lungs and gets lodged there Nursing Safety Priority Monitor patients who are at risk for PE through SSX - Shortness of breath - Chest pain - Hypotension If these SSX are present, the RRT should be notified Patients may also experience the feeling of impending doom which is caused by hypoxemia Patient safety and Quality Care Apply oxygen by nasal cannula mask Reassure patient correct measures are being taken Place patient high-Fowler position Apply tele monitoring Obtain IV access Assess O2/lung sounds Q 30 minutes Petechiae is from lack of clotting factors Assess respiratory status at least every 30 minutes by: Listening to lung sounds Measuring the rate, rhythm, and ease of respirations Checking skin color and capillary refill Checking position of trachea Assess cardiac status by: Comparing blood pressures in right and left arms Checking pulse quality Checking cardiac monitor for dysrhythmias Checking for distention of neck veins Ensure that prescribed chest imaging and laboratory tests are obtained immediately (may include complete blood count [CBC] with differential, platelet count, prothrombin time, partial thromboplastin time, D-dimer level, arterial blood gasses). Examine the chest for the presence of petechiae. Give prescribed anticoagulants. Assess for bleeding. Handle patients gently. Institute Bleeding Precautions. Types of Pulmonary Embolisms Air - air thrombolist occur when central lines are not removed properly Thrombus - from DVT Foreign Object - not naturally formed in the body Isolated - 1 or 2 spots Scattered - many in the lungs Diffuse - a bunch Without infarct - tissue is still alive With Infarct - tissue has died Recognition of PE SSX: dyspnea, “im gonna die” Diagnosis v/q lung scan will show wedge pressure and pulmonary hypertension - will show overall ventilation Well’s Criteria: PE likely > 4 PE unlikely < 4 = used to assess if they actually do or don’t have a PE Treatment Immediate: maintain respiratory status (SaPO2 95%), anticoag therapy, hemodynamically unstable = heparin Long term: IVC filter surgical placement; complication is a ruptured vena cava pulmonary embolectomy - via angiography; can result in pneumothorax, hemothorax, and infarct If DVT is large, it can break up into many little pieces and an occlusion can occur FIBRINOLYTIC = things that will dissolve the clot Nursing Priority Patient education: When bleeding should be expected! Some bleeding when brushing teeth is expected but blood in the stool is not!  Diagnostic Testing Mediastinal Shift: when something is obviously pushing on the lungs and seen in the chest CAUSE: pleural effusion (fluid build up) or pneumo/hemothorax Tracheal Shift: when there is a shift of the trachea CAUSE: trauma to the neck/hemo or pneumothorax Both findings are emergencies as the patient can lose their airway quickly Auscultation - Listening for abnormal sounds Pleural effusions: accompanied by a plural friction (rub); scraping sound like grating, creaking, crunching heard (like walking on snow) Pulmonary edema: gurgling sounds due to pushing and build up of fluid (like a washing machine); patients make grunting sounds or wheezes Labs to check pulmonary status CBC is used to check for oxygenation through HBG Also check neutrophils to see if patient has an infection present/inflammatory process CMP is used to determine acidosis or alkalosis through HCO3 and CO2 ABG is done when is serious respiratory problem is present to determine respiratory acidosis or alkalosis Sputum culture for aspiration patients; pneumonia patients need this done so appropriate drugs can be prescribed - think disc with ABX and rubbing sputum to figure out with is ABX resistant and which can treat the infection Imaging X-ray: Posteroanterior, left lateral, looking for: PNA, effusions, atelectasis, thorax, tumors Pushing or growing on lungs; fluid is visible; skeletal structure (for fractures); 3-D visual CT/MRI: soft tissue Non-Contrast: clots, lesions Contrast: enhance tumors, vasculature, cardiac chamber (iodine + shellfish = allergy hand in hand) Assess for sensitivities: shellfish, diabetics Non-invasive diagnostic SaO2 Capnography: measurement of CO2 that has expired (end-tidal Co2) for patients who may still be retaining CO2  V/Q: used for patients with pulmonary embolism; assesses the V(ventilation)/Q (perfusion pressure) ratio in the lungs; normal is about 0.8 Exercise testing: measures the body’s ability to efficiently exchange gas as demand increases Pulmonary function tests - we are looking for lung compliance 1) TLC (total lung capacity) - 2) Tidal volume (TV) 3) Vital capacity (VC) 4) Residual volume (RV) 5) Forced expiratory volume in 1 minute (FEV1) Invasive Diagnostics Labs ABG Bronchoscopy: insert scope in patients trachea and into the bronchi; mild sedation; numb trachea; NEED TO ASSESS IF PATIENT CAN SWALLOW POST BRONCHOSCOPY Lung biopsy: incision on side of the chest; insert device that cuts out part of tissue; CT guidance for intended area - used to diagnosis cancer and idiopathic interstitial pulmonary function Thoracentesis: used to remove fluid from the lung; Important= post procedure is to assess for vital signs, bleeding, and a potential pneumothorax (upper lobes because fluid will rise and fluid will fall) This procedure should be paused at 1-1.2 L of drainage to avoid hypotension due to lack of vascularity Chest Drainage System Check textbook Chapter 24 Chest tube management 1 box 3 bottles 1) Suction Control Chamber/Dry Suction Chamber 2) Water Seal Chamber 3) Collection Chamber Recognizing an air leak is important because it could mean that air is returning back to patient Chest drainage system will show a ton of bubbling If patient does have a pneumothorax then you would expect gentle bubbling Set to 20 cm of water; number becomes negative when trying to create negative pressure in order to force fluid out of the lungs Room air - water seal dependent on room air 3 types of systems 1) Dry seal; 3 bottle system (most common) 2) Water seal 3) Dry suction Water seal Insertion of the chest tube Purpose: to remove water or air Longer term Thoracentesis : shorter term Nursing priority Chest tube tray Sterile gloves Starts like a thoracentesis but the patient lies flat Inserted high or low dependent on if we are removing air or fluid Post procedure consideration - Bleeding - Vitals - Re-accumulation - Subcutaneous emphysema; where air escapes into the surrounding tissues and patients chest area under the skin has a crunchy area Routine Care - Must have two hemostats - Sterile Occlusive Dressing In case there is an air leak or if chest drain is pulled out - Monitor vital signs for respiratory status every 4 hours - See if there is any sign of mediastinal shift or tracheal shift = tension pneumothorax or additional emergent problem - Assess drainage; amount/color/clarity If patient has a pneumothorax: patient will have hella drainage with small amount of blood (bubbling but never excessive) If patient has hemothorax: color should change from bloody to that serous colored fluid - Tidaling and bubbling: rise and fall with water seal in each breath Dressing change Sterile technique Frequency per protocol Check if sutures are intact Ensure that the pigtail (tube in patient) is still intact and in place Drainage system replacement Exhale, clamp, disconnect old unit, connect new unit (all in under 1 minute) When to call provider 1) Tracheal deviation 2) Any confirmed air leak (needs assessment and XRAY) 3) Any tube dislodgement 4) Drainage - if it stops in first 24 hours then there is an occlusion - typically a hematoma at the tip 5) Signs of respiratory decline Special systems Ambulatory - portable system (dry seal) Heimlich Valve - does not have a valve connected; will attach bag if needed/open air if drainage needed Pleurostat - for malignant pleural effusion = build up of fluid never stops Home health care nurse needs to change this dressing as patients are susceptible to infection Flu and Covid-19 Fluid is airborne - virus loves the cool and moist weather (fall and winter) Two different types: A and B Enters respiratory system and causes an acute infection Hand hygiene is so important because this virus is airborne Risk factors Over 50 years old Chronic condition Immunocompromised Healthcare professionals Prevention for Flu Herd immunity - so many people in that area have been vaccinated against the disease that it can not take hold in that area Vaccines Inactivated Recombinant Live attenuated Types Injection Nasal Spray Recognize Cues: super important that people are contagious for 24 hours to 5 days Symptoms can linger for weeks because it takes lungs a while to heal and expel Take Action: Rapid Influenza Diagnostic Test Still need to be managed based off of symptoms If test positive, patient is put on an antiviral (tamiflu) start in 2 days of symptom onset COVID-19 Recognize cues: see Box 25.1 Vaccinations: Box 25.1 Risk Factors See Box 25.2 Age, chronic conditions Take Action Testing Nasal swabs (home or clinic) See table 25.1 Antiviral Therapy Seek medical attention If rebound covid Difficulty breathing High Fever Severe headache/confusion Isolation Quarantine until you have no fever for 24 hours at home Hospital - patient is placed on droplet precautions and negative pressure room See Box 25.4 and 25.5 Patient Care Rest and Fluids Tylenol Monitor respiratory status - for nebulizer treatments Monitor cognitive status - sepsis and hypoxia Pneumonia At-risk populations Leading cause of death in the elderly GERD increases the risk See table 28.2 and 28.3 Classifications - Location of access See table 28.1 Cause Infectious - bacteria, virus, fungus, other Non-infections: toxins, fumes/smoke, aspiration (happens when elderly/dementia patient forget the sensation of swallowing) Prevention Vaccines - reserved for those at highest risk in the elderly patient setting Behavior: see box 25.1; avoid large crowds especially in the fall/winter, hand hygiene, and no smoking Pathophysiology See table 28.3 Agent causes inflammation of alveoli >> alveoli fill with fluid or pus >> fluid or pus inhibits air exchange >> fluid or pus causes phlegm and cough >> results in fever, chills, dyspnea \ Signs and symptoms: see table 28.3 H&P: Box 28.1 Medical Equipment: VAP/NGT/Inbutated or Ventilator who is at risk of aspiration who will not be able to handle emesis Recognize cues - Resp rate and effort - SaO2 - Sputum - Crackles/Wheezing Fatigue/Malaise - due to underlying infection and inflammation Chest weakness/pain Diagnostics Labs: CBC/CMP/Sputum culture and sensitivity/ABG (acidosis) Imaging: XRay (how much involvement of consolidation - fuzziness where pneumonia is; Thoracentesis; aim is to identify microbe causing the infection then figure out what antibiotic will help combat that Culture sensitivity before we give antibiotics If Empyema (pus in filling in the lungs) is impairing the gas exchange then a thoracentesis is done Take Action Maintain O2 - provide oxygen and promote pulmonary toileting (involves cough deep breath or incentive spirometer) Maintain airway - bronchodilators, pain management, HOB elevated so chest and head are at an angle that can help aid in breathing so diaphragm is supported, hydration Sepsis - caused by antimicrobial infection can potentially lead to aspiration so nurses wanted to minimize lung damage Empyema - Assess lung sounds; thoracentesis/chest tubing Recovery Can take a long long time; complete full course of antibiotics; can develop a resistant infection; smoking cessation Tuberculosis Mycobacterium tuberculosis Takes a long ass time to get rid of Airborne/droplet transmission - droplets become aerosols (laughing singing whistling) Negative pressure room Exposure vs infection Latent - non infectious phase Active - secondary TB and is contagious during this time Infection start in the upper lung and cause lymph nodes to swell and lungs to become inflamed Inflammation Stated above can lead to Pneumonitis - patient may have productive cough Risk Factors Developing countries Constant close contact with an infected person (dense living situations) All have to be tested for TB Immune deficiency Dialysis! Homelessness and IV drug users Low socioeconomic groups Recognize Cues Potential exposure Progressive Became more and more tired and consistently lost more and more weight and had a low grade fever Night Sweats Fever and chills Persistent productive cough - hemoptysis (coughing up blood) Shortness of breath/Dyspnea on exertion Diagnostics XRAYs - fibrosis Labs - CBC/CMP Sputum IGRA - tests body immune response for TB; best to test in latent period Mantoux skin test Figure 28.3 Induration Read after 48 hours Swelling with hardness Greater than 10mm Take action Patient must adhere to treatment to prevent risk of drug resistant TB We want patients to eat their favorite foods to gain adequate nutrition since they are losing a ton of weight Patient Education Assess ability to adhere to drug regimen due to long duration Liver damage and severe N/V if taken with alcohol Monitor themselves for signs of jaundice INH must be taken on an empty stomach Refantin can cause reddish staining on the skin and urine PZA can exacerbate gout Vision disturbances CHEST TRAUMA Thorax: something between the chest wall and the lungs usually in the pleural space; this causes the affected portion of the lungs to collapse and to not be able to expand back. Pneumothorax: air in the chest wall that presses against the lung Cause: blunt trauma that forces air out of the alveoli and into the pleural space Ex) car accident, hit with an object Hemothorax: occur in the young, tall and thin, often male Cause: Trauma, procedures Anticoagulation therapy! Pneumohemothorax: Both; nurses must check for a tension pneumohemothorax as it can be life threatening Mediastinal/tracheal deviation Cause: trauma, coronary artery bypass SSX Respiratory distress DIMINISHED LUNG SOUNDS IN ONE AREA  AIR HUNGER - gulping with breath as they are trying to eat the air Tension pneumohemothorax can cause tracheal or mediastinal changes - if happens call rapid response team and prepare for intubation/chest tube placement Diagnosis ABGs CBC with differential - if infection is a part of the problem Coagulation - to see if clotting is an issue D-Dimer - for inflammation Xray: for involvement of thorax Take action Anyone with a thorax will anticipate a thoracentesis/chest tube placement Chest Injury Damage to the rub cage - Blunt trauma - Car accident No open, external wound SSX Pain from trauma Respiratory distress Paradoxical chest wall movement Flail Chest - intrudes inhalation extrudes exhalation Take action Flail chest = ventilator (monitor this device) Humidified air Monitor ABGs, vital capacity, see for worsening of hypoxemia/hypercarbia Need to know what to do in the event the alarm sounds Open Pneumothorax “sucking wound” Penetrating wound - bullet or knife You will hear air being pushed out the hole on inspiration and pulled back in on expiration The wound does not puncture lung but the loss of pressure from outside the lung means air cannot move into the lung itself Chest tube dislodgement occurrence Recognize Cues Chest wound - with or without bleeding/foaming Audible sound - hissing/sucking Mediastinal shift - alternates with ventilation Respiratory distress - hemoptysis (blood in sputum) Take Action  Wound must be sealed - one way valve with only 3 sides sealed so air can come out on inhalation and seal on expiration Monitor for tension pneumothorax, blood pressure, and heart rate and pattern